Many Asian countries report the rising incidence of eating disorders (EDs) (Gordon, 2001; Mond et al., 2010; Pike et al., 2011; Wan et al., 2003). The gap is closing between several Asian countries (such as: China, Korea, Taiwan, Japan, Singapore and Hong Kong) and the West with regards to both clinical pathology, as well as more widespread disordered eating, weight and shape concerns, and dieting behaviours (Lee et al., 2010; Mond et al., 2010; Pike et al., 2011; Pike & Dunne, 2015; Tsai, 2000; Wan et al., 2003). Even in Asian countries where EDs are believed to be less prevalent than in the West, comparative studies have emerged documenting eating attitudes and body dissatisfaction levels that are similar to or worse than those reported by individuals from Western countries (Kayano et al., 2008; Jung & Forbes, 2006; Jung et al., 2009; Jung et al., 2010; Tsai, 2000). A meta-analysis of 35 published studies showed that eating disorders have the highest rate of mortality of any mental illness, with a weighted annual mortality rate of 5 per 1,000 person-years (Arcelus, Mitchell, Wales, & Nielson, 2011).
Eating disorders among Asian women have been hypothesized as a way for women to express distress without risking the family’s loss of face (Yokoyama, 2007) or violating the norm of emotional restraint (Jackson, Keel & Lee, 2006). Ting and Hwang (2007) assert that intergenerational cultural strain can lead to fundamental misunderstandings about love and care, as when parents use culturally normative child-rearing practices such as criticism and shaming with more acculturated daughters. Criticism applied to achievement, often culturally normative, may include focus on weight and appearance as well. Collectivist values may lead some women to try to achieve status and honour for the family through extraordinary measures (Hall, 1995; Smart, 2009).
Chng and Fassnacht (2015) explored the relationships between different categories of parental comments, body dissatisfaction, and disordered eating concerns in young men and women in Singapore. The study found that negative maternal comments emerged as a consistent predictor of body dissatisfaction and disordered eating for both genders (Chng & Fassnacht, 2015). The findings indicate that there are potential differences in Western and Asian parental influences on eating disorders. Asian mothers seem more influential than Asian fathers, a discrepancy that is greater in Asian than Western cultures.
Sue and Sue (2003, p.342) encourage therapists working with Asian clients to use “problem-focused, time-limited approaches that have been modified to incorporate possible cultural factors”. CBT is considered to be consistent with many Asian cultural values due to its educational, unambiguous, and solution-focused style (Hall & Eap, 2007). The deliberate emphasis on collaborative action, combined with a relative lack of emphasis on the past or family has made CBT acceptable to Asian clients and families who consider emotional problems to be highly stigmatising and prefer treatment to be practical and non-invasive (Smart, 2009).
Family Based Therapy: The Maudsley Model
The Maudsley model of family therapy for children and adolescents with anorexia nervosa, integrates principles and skills from a variety of models (Dare, 1985; Lock et al., 2001). The Maudsley model is of prime importance because of its non-pathologising approach to families, because its techniques have been published in sufficient detail for standardised application by clinicians, and because of its strong history of empirical support (Rhodes, 2003). This model integrates principles and skills from many of the major schools in family therapy and is suitable for adolescents where there is less than three years duration of anorexia nervosa. It has been shown to be suitable for clients and families from CALD backgrounds (Rhodes, 2003).
The Maudsley model aims to break cycles of parental guilt and resulting criticism of their child. The anorexia (rather than any family members) is personified as the oppressor, and its influence on the family is mapped. Parental guilt can be perceived as another ‘trick’ of the anorexia. The parents can then be freer to take charge of the anorexia in the relative absence of criticism of the child. Very firm and insistent stands can be taken while maintaining the adolescent’s need for autonomy. Parents are encouraged to rely on their own expertise regarding refeeding techniques and reaching goal weights and are therefore a resource for the patients’ recovery rather than the cause of the illness.
Engaging the family
- This first meeting is of crucial importance in engaging with CALD families. It is important for clinicians/therapists to establish their roles and credentials. It may take 3-4 sessions to establish trust and rapport with the family.
- It will be helpful, where possible to use culture/language matched clinicians and therapists.
- It is important to establish who the family decision-maker, and care-taker/s are and to ensure that they are informed and consulted.
- Adopting a directive approach towards mobilising the parents’ sense of responsibility for refeeding their child will be more culturally acceptable.
- Where English is a second language, the use of a (preferably mental health trained) professional interpreter is important. Written communication may need to be translated. Be aware that the gender of and choice of interpreter may be important for families.
Psychoeducation:
- The first step is to employ circular questions to explore the effects of ‘the anorexia’. Family members can be encouraged to argue against the parent-blaming view that is held by the illness. The therapist also encourages the family to separate the patient from the illness by stressing how little control the patient has over these behaviours, and how it has gradually overtaken her.
- Features of anorexia, such as distorted concepts of body image, food-related anxiety, and water-loading before weigh-ins may also be framed as ‘tricks that the anorexia has gradually employed’ to take control of the patient.
- The technique of collapsing time (White, 1986) is then used to create an intense scene regarding the possible medical effects of prolonged illness. This is an important focus, given that anorexia has the highest mortality rate of any psychiatric illness at 6–15% (Steinhausen et al., 1991; 1993). There are also risks of permanent growth retardation, osteoporosis, cardiac dysfunction, and structural abnormalities in the brain (Fischer et al., 1995).
- The parents are then encouraged to take two weeks off work to start the refeeding process and the adolescent is asked to take two weeks off school. The message the parents are left with can be summarised as ‘It is definitely not your fault, but it must be your responsibility’.
- It is helpful to normalise intergenerational conflict between young people and parents as a common experience in migrant families, as parents/grandparents may feel that they alone are encountering these issues.
Cognitive Behaviour Therapy (CBT)
Cognitive Behaviour Therapy (CBT) is a useful approach to psychosocial interventions with Asian clients if adaptations are made (Smart, 2009). Hall and Eap (2007) suggest that, within clinical reason, therapists resist confronting clients’ views about the aetiology of their problems and work cooperatively with them instead. It is helpful for therapists to pay attention to mind-body connections, possibly incorporating mindfulness practices (Hall & Eap, 2007). Therapists can respect the role of somatic symptoms and work to alleviate them (avoiding the tendency to dismiss somatisation as an inability to feel). It is better to work with face-saving values rather than to try and change them. Self-disclosure in the privacy of therapy for example, can be reframed as a way to solve problems, help preserve harmony in the family, and reduce the potential for problems to escalate (Hall & Eap, 2007). Ting and Hwang (2007) advise that in regard to treatment for eating disorders, therapists, when appropriate, reframe family struggles in the context of acculturation difficulties. While recognising that CBT may be the best approach to body dissatisfaction, therapists should include an exploration of how client distortions are impacted by devaluation of ethnic features in the broader society. Attention needs to be paid not only to weight but to dissatisfaction with particular body parts (Smart, 2009). The case studies offered encourage the use of empirically supported treatments (ESTs) for eating disorders (Wilson et al., 2007) and the provision of treatment that is sensitive to differences in culture (Cummins & Lehman, 2007; Yokoyama, 2007).
Cultural accommodation to the enhanced cognitive behavioural therapy model
Enhanced Cognitive Behavioural Therapy (CBT-E) is designed as a guide for individual therapy (Fairburn, 2008). Called transdiagnostic, CBT-E aims to benefit those with Eating Disorders (ED) who are appropriate for outpatient treatment (Smart, 2009). The enhancement to the model includes attention to mood intolerance, and three other clinical emphases are used when needed: clinical perfectionism, core low self-esteem, and interpersonal problems (Fairburn, 2008). The focus of treatment is to disrupt the factors that maintain the ED, such as helping the client to recognise cognitive biases (eg dichotomous thinking), as would be expected in a CBT plan (Fairburn et al., 2008b). In general, the model seeks to help clients try new behaviours and learn through mindfulness, balancing acceptance and change. The following case study with a Korean client uses a CBT-E approach, which is well suited to the client’s social and cultural situation and models a culturally competent approach to ED intervention.
